1.) Name:    2.) Street Address: 

3.) City:       4.)State:     

5.) Zip Code:    6.)Home Phone:     

7.) Home E-Mail Address (if any):

8.) Do you attend Church (if so where): 

9.) Where do you work (if you work for DuPont what site): 

10.) What is your Work E-Mail Address: 

11.) What is your Work Phone Number: 

12.) Date of Membership:   

13.)                    (please select one)
Do you want this Public:   (if you select public, your name will be added to the table on
                   or Private:   the previous page)
                  
14.) Employment Status:     (please select one)
            Employee of DuPont :
            Contractor of DuPont:
            Retired from DuPont : 
                                Other  :
(Please explain below:

Donations for the upkeep and maintenance of this web site can be sent to: 
              Keith Woods
              880 Robinson Road
              Chillicothe, Ohio   45601